Credit Card Payment Authorization Form
Booking Number/Trip Name:
#1 Traveler's Name:
#2 Traveler's Name:
Full Name as it appears on Payer's Credit Card:
Billing Address:
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Deps
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherland
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
St Kitts & Nevis
St Lucia
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Credit Card Type
Master Card
VISA
American Express
Credit Card Number
Expiration Date (MMYYYY)
Security Code
Payment Amount
Payment Frequency
one time payment
once per week
once per month
twice per month
Contact Phone
Email Address
TERMS and CONDITIONS
In providing our clients with thorough service, Black Soul Rhythms Travel is associated with one or more travel affiliates. Please read the full
Terms and Conditions
. If there is something that needs further clarification it is your responsibility to contact BSR Travel to ask questions.
• Passports: All international trips require a Passport valid for at least 6 months beyond the date of departure. Any and all additional Visa's or travel documents required are the responsibility of the traveler.
• Travel Insurance: Black Soul Rhythms Travel strongly recommends the purchase of Travel Protection that can help minimize the monetary loss incurred due to unforeseen events beyond your control such as: cancellation, missed connections, baggage loss, trip delay, and especially medical emergencies.
• Cancellations: Deposits are non-refundable. Cancellation, revision and refund polices for changes or unused travel/components vary and are subject to the policies of each supplier. Cancellation penalties can range up to 100% depending on how close to departure the written notification is received. Air, travel insurance and no-shows are always non-refundable. Penalties may apply for changes and/or cancellations.
•
Payment Plan: If you choose a payment plan, payments must be paid by the due dates. Late payments may result in cancellation of vacation package.
Please read the full
Terms and Conditions
. If there is something that needs further clarification it is your responsibility to contact BSR Travel to ask questions. Please check and enter your initials below to accept these
Terms and Conditions
and the processing of your payment.
CREDIT CARD AUTHORIZATION
By clicking submit, you certify that you are the card holder and that you authorize Black Soul Rhythms Travel or their suppliers to charge your credit or debit card not to exceed the amount indicated. You are further advised that the posted charge may be in the name of Black Soul Rhythms LLC or Black Soul Rhythms Travel or one of its suppliers or affiliates. You may request from Black Soul Rhythms Travel the name of the affiliate that will appear on your credit or debit card statement.
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I accept the Terms and Conditions: https://www.blacksoulrhythms.com/terms-and-conditions
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